Online Application & Pledge Form

Primary Contact Name

Title

Address

City

State

Zip

Phone

Fax

Secondary Contact Name

Title

Phone

Fax

*Both Primary and Secondary Contacts will receive the monthly WBEC ORV newsletter.

Who should be listed in the online WBENCLink database accessed by WBEC ORV Region WBE's?

Please select

Primary Contact
Secondary Contact
Other

If other, please complete the following:

Name

Title

Address

City

State

Zip

Phone

Fax

Indicate preferred WBENCLink Username

Password

Online Information:

Website Address

May WBEC ORV Hyperlink to your site?

Yes
No

Contact for website information and logo usage:

Name

Phone

Will you link WBEC ORV to your supplier information page on your website?

Yes
No

Other Information:

Do you currently have a supplier diversity program for women-owned business?

Yes
No

If you answer “No,” what is your planned implementation schedule?

If you answered “Yes,” do you...

Require third-party certification?

Yes
No

Accept WBENC certification?

Yes
No

Accept other certifications for WBEs?

Yes
No

Can you provide in-kind support to WBEC ORV?

Yes
No

If yes, please describe

Industry

Products Produced

Products Purchased

Description of Services Provided

Dues Structure: Annual WBEC ORV Dues

Please select

$2,500 Corporate
$1,750 Non-Profit, Government

I UNDERSTAND THAT THIS APPLICATION IS CONSIDERED A COMMITMENT AND THAT MY CORPORATION WILL START RECEIVING MEMBERSHIP BENEFITS ACCORDING TO THE DATE MY APPLICATION IS RECEIVED.

Authorizing Signature

Online Application & Pledge Form

Corporate Membership Application

Company Information: